Catamaran Ehb Standard Formulary
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2021 Essential Health Benefits Base Formulary Effective July 1, 2021 For the most current list of covered medications or if you have questions: Call the number on your member ID card Visit your plan’s website on your member ID card or log on to the OptumRx app to: • Find a participating retail pharmacy by ZIP code • Look up possible lower-cost medication alternatives • Compare medication pricing and options EHB Base Understanding your formulary What is a formulary? About this formulary A formulary is a list of prescribed medications or other When differences between this formulary and your pharmacy care products, services or supplies chosen for benefit plan exist, the benefit plan documents rule. their safety, cost, and effectiveness. Medications are This may not be a complete list of medications that are listed by categories or classes and are placed into cost covered by your plan. Please review your benefit plan for levels known as tiers. It includes both brand and generic full details. prescription medications. ® To create the list, OptumRx is guided by the Pharmacy and When does the formulary change? Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how • Medications, including generics, may be added at any time. well the drugs work, and overall value. They also make sure • Medications may move to a lower tier at any time. there are safe and covered options. • Medications may move to a higher tier or be excluded from coverage on January 1 of each year. How do I use my formulary? If a medication changes tiers, you may have to pay a different You and your doctor can use the formulary to help you amount for that medication. choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and Why are some medications excluded if special rules apply. If your medication is not listed here, from coverage? please visit your plan’s website or call the number on your A medication may be excluded from coverage under your member ID card. pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication. What are tiers? Tiers are the different cost levels you pay for a medication. What if I don’t agree with a decision about an Each tier is assigned a cost, set by your employer or excluded medication? plan sponsor. You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card. Medication tips What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. What if my doctor writes a brand-name prescription? Over-the-counter If your doctor gives you a prescription for a brand-name medication, ask if a medications (OTC) generic or lower-cost option could be right for you. Generic medications are Talk to your doctor about OTC usually your lowest-cost option. options. Even though OTC What if I am taking a specialty medication? medications may not be covered by your pharmacy benefit, Specialty medications are used to treat complex conditions and are generally they may cost less than a higher in cost. Please note, not all specialty medications are listed in the prescription medication. formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask if you can have your prescriptions delivered right to your home or doctor’s office. 2 Reading your formulary The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol). Tier information Using lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible. Drug Tier Includes Helpful Tips Tier 1 $ Generic Use Tier 1 drugs to lower your out-of-pocket costs. Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs. Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you. Tier 4 $$$$ Specialty Generally highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring and handling. Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered. M Authorized generic or cobranded product PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage. PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met. PV* Preventive drugs – Available at $0 if Health Care Reform copay waiver is approved. QL Quantity Limit – Medication may be limited to a certain quantity. ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered. 3 Table of Contents Analgesics......................................................................................................................................................... 5 Anesthetics........................................................................................................................................................ 7 Anti-Addiction/Substance Abuse Treatment Agents.....................................................................................8 Antibacterials.....................................................................................................................................................8 Anticonvulsants.............................................................................................................................................. 11 Antidementia Agents...................................................................................................................................... 12 Antidepressants.............................................................................................................................................. 12 Antiemetics...................................................................................................................................................... 14 Antifungals.......................................................................................................................................................14 Antigout Agents.............................................................................................................................................. 15 Antimigraine Agents....................................................................................................................................... 15 Antimyasthenic Agents.................................................................................................................................. 15 Antimycobacterials......................................................................................................................................... 16 Antineoplastics................................................................................................................................................16 Antiparasitics...................................................................................................................................................19 Antiparkinson Agents..................................................................................................................................... 20 Antipsychotics.................................................................................................................................................21 Antivirals.......................................................................................................................................................... 21 Anxiolytics....................................................................................................................................................... 23 Bipolar Agents.................................................................................................................................................23 Blood Glucose Monitoring............................................................................................................................. 24 Blood Glucose Regulators............................................................................................................................. 24 Blood Products and Modifiers....................................................................................................................... 26 Cardiovascular Agents................................................................................................................................... 27 Central Nervous System Agents....................................................................................................................31 Dental and Oral Agents...................................................................................................................................32 Dermatological Agents..................................................................................................................................